What is the recommended treatment for a patient with an undisplaced anterosuperior labral tear, tiny intralabral cystic change, superolateral chondrolabral junction fissuring, moderate superficial trochanteric bursitis, and intact hip joint articular cartilage?

Treatment Recommendation for Undisplaced Anterosuperior Labral Tear with Chondrolabral Junction Fissuring and Trochanteric Bursitis

Begin with conservative management for 3-6 months, and if symptoms persist, proceed with hip arthroscopy for labral repair using suture anchors combined with management of the chondrolabral junction fissuring. 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative treatment should be attempted before surgical intervention and includes:

• Rest and activity modification to avoid provocative movements, particularly those involving hip flexion and internal rotation 3
• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain control and reduction of trochanteric bursitis inflammation 3
• Physical therapy focusing on hip stabilization and core strengthening 3
• Intra-articular corticosteroid injection can serve both diagnostic and therapeutic purposes, with appropriateness rating of 5/9 4
• Aspiration consideration for any painful, tense effusions 1

The trochanteric bursitis component typically responds well to NSAIDs, activity modification, and targeted physical therapy. 3

Indications for Surgical Intervention

Proceed to arthroscopic surgery when conservative management fails after 3-6 months, as untreated labral tears lead to persistent pain, progressive cartilage damage, and potential osteoarthritis development. 1, 2

Surgical Approach

Labral Repair Technique

Arthroscopic labral repair using suture anchors is superior to simple debridement because it preserves the sealing function of the labrum and maintains proper load distribution in the hip joint. 2, 5

• Perform arthroscopic repair of the anterosuperior labrum with suture anchors 2, 5
• The labrum should be detached from the acetabular rim to allow proper repair 6
• Suture anchors are placed in the acetabular rim after appropriate preparation 6, 2

Management of Chondrolabral Junction Fissuring

For the superolateral chondrolabral junction fissuring, the treatment depends on the appearance and size of the lesion:

• If the delaminated cartilage appears macroscopically healthy and the lesion is small (<3 cm²): Repair with sutures or fibrin adhesive is the preferred option 6, 2
• If debridement is required: Follow with microfracture of the exposed subchondral bone for lesions <3 cm² 6, 1
• Create microfracture holes in the subchondral bone using an awl to promote healing 6

The study by Stafford et al demonstrated significant improvement in pain scores from 21.8 to 35.8 (P < 0.0001) and function scores from 40.0 to 43.6 (P = 0.0006) at 28 months following this approach. 2

Evaluation for Femoroacetabular Impingement (FAI)

Assess for and correct any underlying FAI during the same surgical procedure, as FAI is commonly associated with anterosuperior labral tears and delamination lesions. 6, 2 Failure to address underlying FAI will result in recurrent labral pathology.

Important Caveats and Pitfalls

• Cartilage repair is only appropriate for small delaminated lesions with limited evidence supporting this technique in the hip despite relatively favorable outcomes 2
• Avoid stem cell injections for cartilage regeneration due to lack of standardization, as advised by the American College of Rheumatology/Arthritis Foundation 2
• Hip arthroscopy has a steep learning curve and should be performed by experienced surgeons to minimize morbidity 5
• The intact articular cartilage in this case is a favorable prognostic factor, as extensive cartilage damage is the most important determinant of surgical outcome 2

Post-Operative Management

• Implement a structured rehabilitation protocol with gradual progression of weight-bearing and range of motion 1, 2
• Regular monitoring for symptom recurrence or progression is essential, as chondromalacia can progress to osteoarthritis if not properly managed 2
• At 1-year follow-up in repair cases, mean Harris Hip Scores improved from 53.3 to 80.3, with pain scores improving from 15.7 to 28.9 6

Prognosis

89% of patients report clinical improvement at an average of 16.4 months after hip arthroscopy for labral tears. 7 The presence of intact articular cartilage and the small size of the chondrolabral junction fissuring are favorable prognostic indicators in this case. 2